ENT Coding

Evaluation and

Management

Documentation Requirements

• Wellmark accepts both 1995 and 1997 E/M documentation guidelines

• Use 1995 or 1997 guides for general multisystem exams

• Use 1997 guides for single system exam– Effective use of 1997 guidelines often

requires special training and monitoring

4

The Note

• Record must be complete and legible

• Even the signature or identification

• Record stands on its own…but can incorporate by reference

• Medical necessity, above all else, must be documented in record

Place of Service

• If patient seen in outpatient facility clinic or office for scheduled visit, use POS 11– “Scheduled” means planned

• Patient has an appointment for a specific day and time

• Do not use hospital POS

Outpatient Consults

• Consults must document request and reply– “Written or verbal request . . . may be made by a

physician or other appropriate source and documented in the medical record”

– “Consultant’s opinion and any services . . . ordered or performed MUST also be documented in the patient’s medical record AND communicated by written report to the requesting . . . source” [emphasis added]

• ER Consults– Usually referrals, not consults

Outpatient Consult Rule

• Consults = gives advice– Bill for consults when the physician

is asked to provide an opinion on diagnosis or treatment

• Referrals = takes over patient care– Bill for new or established patient

visits if there is no intent to return care to the original provider or this condition

Inpatient Consults

• Use 99251 - 99255 for initial consult per inpatient admission– New or established patient, new or

established problem– Must still meet criteria for consult

• Use Follow Up Inpatient consults (99261 – 99263) in two situations– A consult requires 2 visits to complete– Same physician is consulted again during the

same admission• RVU better for subsequent hospital visit

Confirmatory Consultations

• Use 99271 – 99275 when a second or third opinion is requested for advice only– If care is initiated, confirmatory

consults cannot be billed

• Use modifier 32 if the second opinion is required for coverage requirements– A few Wellmark contracts require

second opinions for surgery

Observation care

• Use codes 99217 – 99220 for admit and discharge on different calendar days

• Use codes 99234 – 99236 for admit and discharge on same calendar day– More than 2 calendar days use 99211 -

99215 for extra days

• No minimum hours for Observation codes, based on admission status

Modifiers

• Use modifier 57 for E/M day before or day of major surgery when decision for surgery made that day– Documentation must support decision for

surgery– Use modifier 57 on day of surgery for

global period of 90 days

• Use modifier 25 for E/M on day of minor procedure (global of 0 or 10 days) – Must be separately identifiable E/M beyond

clearance for procedure

E/M and Supplies

• Supplies only billed if they are over and above those usually included with the office visit– Wellmark considers nonprescription or

over-the-counter drugs, vitamins, minerals, or nutritional supplements noncovered materials.

• Bill with code 99070– Provider manual is being corrected, shows

code 99071

Surgery

Surgical Package

• Follow CPT surgical package• Each procedure includes

– Operation per se– Local infiltration,

metacarpal/metatarsal/digital block or topical anesthesia

– Subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of procedure (including H&P)

– “Typical” postoperative follow-up care• Wellmark follows Medicare’s global periods

Pre and Postoperative Care

• Bill surgery with modifier 54 if surgeon performs surgery only

• Use E/M codes to describe preoperative services by other physicians

• Use modifier 55 with surgical procedure code to describe postoperative care

Office Surgery and Supplies

• Most supplies bundled into office surgery– Separate billing for surgical trays or

casting material

• Use HCPCS codes for separately billable supplies– Example: A4550 – Surgical tray

• Use unlisted HCPCS as last resort and include written description of supply on a paper claim

Modifiers

• Generally follow CPT guidelines for use of modifiers

• Currently use one modifier per CPT/HCPCS code on CMS-1500– Need more than 1 use modifier 22 and

send letter and copy of note– Multiple modifiers available 03/01/04

Bilateral Procedure

• Same procedure performed on each side of the body at the same time– Use Medicare Fee Schedule Data Base

indicators for specific procedures– Reimbursement is 150% of allowable

• List procedure once with 50 modifier and 1 unit– Don’t use 50 on Radiology codes, use units– Don’t use modifier 50 on procedure

described as bilateral

Postop Modifiers

• Use modifier 24 for unrelated E/M in postop period

• Use modifier 58 for planned additional services in the global period or services related to the same underlying condition

• Use modifier 78 when a postoperative complication requires a return to the OR

• Use modifier 79 unrelated services in the postop perior or for postop complications that don’t require return to the OR

Assistant Surgeons

• Physicians use modifiers 80, 81, or 82– All reimbursed at 25% of the primary

surgeon’s fee• Use modifier 82 only in a teaching setting

when no qualified resident is available

• PAs, and ANRSs use modifier AS for assistant– Paid at 21.25% of primary’s allowable

• Procedure must be listed on Wellmark assistant-at-surgery list (See Wellmark Specialty Services guide on web)

• If available, list NPPs nonbilling number in field 24K of CMS-1500

Cosurgery• Two surgeons work as primaries on part of a

service described by a single CPT code– ENT surgeon provides approach and closure of

anterior cervical spinal surgery– ENT surgeon provides approach and closure of

intracranial procedure

• Each surgeon bills same CPT code with modifier 62

• Reimbursement is 62.5% of allowable for single surgeon

• HINT: Coordinate billing with both offices

Skull Base Surgery

• Codes 61580 – 61619– Codes can’t be used if one surgeon performs

approach, closure and definitive procedure

• ENT surgeons often perform approach and closure– Approach and closure codes can only be used with

definitive procedure codes 61600 – 61616• Otherwise use 61304 – 61576 with modifier 62

– Be sure approach code matches location of definitive procedure

– Primary closure is bundled into definitive procedure

Cauterization of Turbinates

• Chemical cauterization of nasal turbinates for treatment of nasal obstruction is a non-payable service– Use the CPT code 30999 to report– Nasal endoscopies, CPT code 31231,

on the same day will also be denied.

Concha Bullosa Resection

• May be billed separately sometimes– Separately payable with 31256

(endoscopy with maxillary antrostomy) and 30140 (submucosal resection turbinate)

– Considered incidental to 31255 (endoscopy with total ethmoidectomy) and 30130 (excision turbinate)

• Denials may be appealed with good documentation

Impacted Cerumen

• Only code 69210 if there is a significant amount of physician or physician supervised work– Installation of drops, minor scraping,

or simple irrigation is bundled into E/M

• Bill separate E/M service with modifier 25 and 69210 if there is documentation of significant work

Removal of Cerum With Audiology Services

• Removal of cerum considered integral to audiology service

• Use modifier 22 if substantial additional work required

• Submit with documentation

Sinus Endoscopy

• Codes 31231 – 31294 for use of nasal/sinus endoscope as approach

• All therapeutic codes include diagnostic endoscopy – Diagnostic codes (31231 – 31235) include

inspection of interior nasal cavity and middle and superior meatus, turbinates, and spheno-ethmoid recess

• Code 31238 cannot be used for control of bleeding associated with the endoscopy

Postop Sinus Debridements

• Wellmark will pay for three postop sinus debridements– Any more would require explanation

• Bill with CPT code 31237– Do not use S2342– Bill with modifier 79 for unrelated

procedure in postop period

Panendoscopy

• Bronchoscopy, esophagoscopy, laryngoscopy at same session– Laryngoscopy bundled into bronchoscopy

• Would need significant documentation to support both services

– Esophagoscopy could be separately bill • Use modifier 59 to indicate separate service

• Must meet medical necessity requirements

Computer Assisted Endoscopic Sinus Surgery (InstaTrac)

• Prior approval required• Indications

– Anatomic landmarks altered• Fungal infection, neoplasms, altered nasal

anatomy, post operative sinus changes, more than two sinus polyps

– Request for surgery done on frontal sinuses will be individually reviewed by the medical director.

• Use code 61795 for stereotactic computer-assisted volumetric procedure in addition to the primary procedure code

CPT 2004

• No significant changes specifically impacting ENT– Watch new subsection for placement

of central lines

• Check Appendix B for changes specific to your practice

Resources

• Check Wellmark website for general and specialty specific guidelines– www.wellmark.com

• Check Medicare website for Medicare Fee Schedule Data Base– Lists global days, appropriate

modifiers, bilateral procedure, etc.– www.cms.gov